Raising the Standard: An Overview of Fellowship Education in Bariatric Surgery

| February 1, 2022

by Anthony T. Petrick, MD, FACS, FASMBS, and Dominick Gadaleta, MD, FACS, FASMBS

Dr. Petrick is Chief Quality Officer, Geisinger Clinic; Director of Bariatric and Foregut Surgery, Geisinger Health System in Danville, Pennsylvania. Dr. Gadaleta is Chair, Department of Surgery, South Shore University Hospital; Director, Metabolic and Bariatric Surgery, North Shore and South Shore University Hospitals, Northwell Health in Manhasset, New York; Associate Professor of Surgery, Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York.

Funding: No funding was provided for this article.

Disclosures: The authors report no conflicts of interest relevant to the content of this article.

Bariatric Times. 2022;19(2):14–15

“Education is what remains after one has forgotten what one has learned in school.”

-Albert Einstein

In the January issue of Bariatric Times, Raising the Standard reviewed the current quality standards for bariatric surgical fellows. This month, we would like to take a closer look at the educational experiences of bariatric surgical fellows. 

As with case logs, documentation of all components of a fellow’s bariatric training is required. Both clinical and skills training must include perioperative care, as well as bariatric operative and endoscopic skills training.  Didactic educational sessions require fellows to understand all key elements of bariatric surgical programs. Fellows must learn the clinical role of the dietitian and behavioral medical team as well as the bariatrician—and use this information in surgical decision-making. Fellows are expected to participate in bariatric medicine office patient visits. 

Defined technical skills training in and out of the operating room is compulsory. It is imperative that bariatric surgical fellowship enhance, and not undermine, the experience of surgical residents. Both the Fellowship Council (TFC) and the Accreditation Council for Graduate Medical Education (ACGME) require that the surgical residency and bariatric fellowship work in a complementary manner to maintain accreditation. Chief residents should not share clinical responsibilities with the bariatric fellow. Fellows should not routinely operate with the chief resident, but when operating together, it is expected that the fellow function in a mentorship role, delegating the primary surgical role to the chief resident. When working with more junior residents, fellows should provide the surgical resident with increasing responsibility for progressing through the case in accordance with the postgraduate level and individual skill set. 

Additionally, the teaching of bariatric surgical fellows should be an active process. Bariatric cases lend themselves well to cognitive task analysis and modular teaching. Bariatric procedures should be approached in discrete segments. Defined goals for port placement, tissue manipulation, stapling, use of energy device, and suturing should be created for each segment with objective measures of progress. Fellows should be encouraged to utilize case videos to assess their progress. Most importantly, fellows must have discrete timelines and goals to progress toward autonomy. 

True autonomy is a distinct advantage of nonstandard (nonACGME) fellowships. Board-eligible or certified fellows can be credentialed for independent operating privileges within the scope of their expertise. Their services are reimbursable. Besides the contribution this can make toward the fellowship expenses, nonstandard fellows are not subject to the Centers for Medicare and Medicaid Services (CMS) restrictions from autonomous surgical care if they qualify to be fully credentialed. TFC is cognizant of the incentive this creates for hospitals to prioritize the revenues, rather than the education, in bariatric fellowships. TFC considers any such deviation from the educational mission as grounds to deny accreditation.

While the scope of residency training precludes competency in all required cases, the bariatric fellowship mandates that fellows achieve autonomy. Competency is not sufficient. Fellows must achieve proficiency.1 

Beyond clinical expertise, the bariatric fellowship experience is designed to prepare trainees for autonomous practice. This is the fellow’s terminal training. Leadership training within the fellowship should give the graduated fellows educational and administrative responsibility. This includes ownership of agendas and content for conferences, such as morbidity and mortality reviews. The fellows should also be provided autonomy to develop resident didactic and technical educational content.

Bariatric fellows should be familiar with the Metabolic and Bariatric Surgical Accreditation and Quality Improvement Program (MBSAQIP) standards for accreditation. This information is critical to fellows as they enter into practice. Many fellows will receive offers to start up bariatric programs. Their career choices should be made with an understanding of their employers’ commitment to provide adequate resources to build a safe and successful bariatric program. In my personal experience, most employers are not prepared to invest in the necessary resources when recruiting our fellows to “build” a new bariatric program.

Fellows should also receive targeted education in service line development. Unlike many residents in medical specialty, surgical residents receive very little exposure to the “business” of medicine. Terms like current procedural terminology (CPT) and relative value units (RVU) are familiar to most surgical residents only as acronyms. Their definitions and relevance to clinical operations should be the focus of specific didactic sessions. Fellows need to understand the CPT and RVU for bariatric surgical and endoscopic procedures. They should receive instructions explaining the reduction in reimbursements when procedures are done in combination and have the knowledge base to weigh the clinical and financial factors associated with complex procedures. 

Understanding the “business” of medicine will prepare bariatric fellows to comprehend service line development. This includes the engagement of other disciplines, as well as facility needs, both of which are required to build and sustain a comprehensive bariatric program. Fellows must be familiar with care pathways and how to create them. Finally, the fellow’s education should include an introduction into quality improvement. MBSAQIP standards require a biannual review of outcomes data and a targeted quality improvement project for metrics that fall in the high outlier range. Future columns will focus on MBSAQIP standards in more detail.

Through a comprehensive system for evaluation and feedback, TFC ensures that accredited bariatric surgical fellowships fully prepare the bariatric surgical fellow to enter into clinical practice as an expert surgeon, clinician, and surgical leader.2  


  1. Wehrtmann FS, de la Garza JR, Kowalewski KF, et al. Learning curves of laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy in bariatric surgery: a systematic review and introduction of standardization. Obes Surg. 2020;30(2):640–656.
  2. The Fellowship Council. https://www.fellowshipcouncil.org/program/. Accessed 24 Jan 2022.

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Category: Past Articles, Raising the Standard

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